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Revamping weight loss for heart health

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Revamping weight loss for heart health Lucy Aphramor RD Senior Health Promotion Specialist Diet and Cardiovascular Health Atrium Health Ltd. – PowerPoint PPT presentation

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Title: Revamping weight loss for heart health


1
Revamping weight loss for heart health
  • Lucy Aphramor RD
  • Senior Health Promotion Specialist
  • Diet and Cardiovascular Health
  • Atrium Health Ltd.

2
Therapeutic Relationship
  • Respect
  • Evidence based
  • First do no harm

3
Energy Balance Metaphor
health
energy expenditure
Kcal
4
Why encourage weight loss?
  • .
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5
BHF Reducing your blood cholesterol
6
BHF Eating for Your Heart
SIGN references one study that provides data
showing that intentional weight loss decreases
risk of chronic disease.
Williamson DF et al, Am J Epidemiology, 1995
7
British Dietetic Association
Size Matters 2004, BDA
8
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9
BBC Wales, Welsh Assembly Government.
10
  • Its about making you feel bad about
  • yourself. That cannot be about anything
  • else than saying at the moment you
  • are not acceptable can it?

11
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12
The beneficial effects of modest weight loss on
cardiovascular risk factors Van Gaal et al 1997
  • n9
  • data on the effects of weight loss on Lp(a) are
    scarce and contradictory
  • possible effects of exercise were difficult to
    determine
  • it cannot be proven that weight loss per se is
    the most important trigger of the reduced
    mortality

13
Studies have investigated whether modest weight
reduction results in improved cardiovascular
morbidity and mortality.
  • One week residential course
  • Low-fat near vegan diet no kcal restriction
  • No caffeine/ smoking
  • Exercise recommendations
  • Group support
  • Stress management

14
Beneficial effects of modest weight
loss Goldstein, D. (1992) Int J Obesity 16,
397-415.
  • obese patients with serious medical
    complications
  • Eg. NIDDM lt1000 patients, n 7 to 118
  • drug treatment, 330kcal/day, relaxation, CBT
  • 4 weeks 18 months

15
Standards and Core Components for Cardiac
Rehabilitation (2007)
  • Diet and weight management CR should include
  • Assessment of body mass index (BMI) and waist
    circumference
  • Use of best practice standards and guidelines for
    dietary prescription and weight management
  • Ref DH guidelines , SIGN No. 97

16
Dattilo Kris-Etherton, 1992
  • 6 of studies had over 50 people
  • 82 of studies had no control
  • 35 studies lasted only 210 weeks
  • not on cholesterol-lowering medication
  • Impossible to identify effect of fat modification

17
Obesity Disease Management Effects of Weight
Loss on Comorbid Conditions Anderson Konz 2001
Ob Res 9(4) 326S-334S
  • Promoting weight loss and maintenance of weight
    loss should have the highest priority in
    prevention and a very high priority in treatment
    of CHD risk factors.
  • increased physical activity expends energy and,
    perhaps more importantly, reminds individuals
  • of weight management task at hand.

18
Why arent there more studies?
19
NEJM Editorial
  • The data linking overweight and death, as well
    as the data showing the beneficial effects of
    weight loss, are limited, fragmentary and often
    ambiguous.
  • Kassirer, et al. Losing weight an ill-fated
  • New Years resolution. NEJM 1998338.

20
Synthesis of systematic reviews of obesity
treatment and prevention
  • Although these were the best studies available
    according to the principles of evidence based
    medicine, many did not fulfil its requirements.
    These flaws bias the results and can exaggerate
    the effects..Rather than showing what does work
    for preventing and treating obesity, research to
    date shows us clearly what does not. (Jain BMJ
    2006)

21
  • Medicares Search for Effective Obesity
    Treatments Diets are not the answer
  • American Psychologist, 2007, 62,3, 220233.

22
Why promote healthy eating and exercise
  • .
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  • .
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23
Improving Health National Institute of Health
guidelines reveal strong evidence that physical
activity alone, without weight loss, reduces the
risk for cardiovascular disease and other disease
factors. Clinical guidelines on the
identification, evaluation, and treatment of
overweight and obesity in adults NIH, 1998.
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26
Lee, C. D., Blair, S. N., Jackson, A. S.
(1999). Cardiorespiratory fitness, body
composition, and all-cause and cardiovascular
disease mortality in men. Am J Clin Nutr 69,
37380.
  • n22,000 men
  • Unfit, lean men had a higher risk of all-cause
    and CVD mortality than did men who were fit and
    obese
  • Unfit men had a higher risk of all-cause and CVD
    mortality than did fit men in all fat and
    fat-free mass categories
  • Similarly, unfit men with low waist girths (lt87
    cm) had greater risk of all-cause mortality than
    did fit men with high waist girths ( 99 cm)

27
JAMA (2005) 293 (15) 1861-1867
  • Excess deaths associated with underweight,
    overweight and obesity
  • Overweight (25 BMI lt30) was not associated with
    excess mortality.

28
PLoS Medicine (2005) 2 (6) e171
  • Intention to lose weight, weight changes, and
    18-y mortality in overweight individuals without
  • co-morbidities.
  • Deliberate weight loss in overweight
    individuals without known co-morbidities may be
    hazardous in the long term.

29
Why recommend dieting?
  • Weight gain
  • Enhance nutritionally inadequate diets
  • Jeopardise metabolic fitness
  • Decrease bone mass
  • Increase eating distress
  • Keep tobacco industry afloat
  • Exacerbate weight cycling
  • Increase discrimination and bullying

30
  • Increase depression
  • Discourage healthy behaviour
  • Completely waste resources
  • Increase exercise addiction/resistance
  • Reinforce sense of hopelessness
  • Promote body hatred in children
  • Poorer prognosis in heart patients
  • Demonstrate professional ineffectiveness
  • Obscure useful research directions
  • Mislead the public

31
Is it ethical to promote weight loss for
overweight adults?
32
Weight Cycling and Heart Health
  • Increase risk of hypertension among women at high
    risk for heart disease.
  • Positive association between body weight
    fluctuation and all-cause mortality, and usually
    with coronary mortality in particular. BNF
    Task Force Obesity

33
CAD and CV Events in Women
  • 906 women followed for 3.9 years
  • Overweight women more likely to have CV risk
    factors but BMI/abdominal obesity not associated
    with adverse CV events
  • Being fat poses less risk for heart disease than
    being unfit
  • Wessel R et al (2004) Relationship of Physical
    Fitness vs. Body Mass Index with Coronary Artery
    Disease and Cardiovascular Events in Women.JAMA
    292 1179-1187

34
European recommendations
  • . state that overweight people after MI should
    be recommended to lose weight. But the
    recommendations are not based on any studies
    because our study is in fact the first in the
    field medical science may have shortened the
    lives of a number of overweight patients with
    myocardial infarction by persuading them to diet.

Willenheimer, 2006
35
BMI and Prognosis in Patients with Chronic Heart
Failure Kenchaiah et al (2007) Circulation
116627-636.
  • Double-blind, placebo controlled 7599 patients
    mean FU 37 months
  • Baseline BMI no influence on risk of
    hospitalisation
  • BMI 30 -35 improved prognosis
  • Increased risk death BMI 35 not sig.

36
Therapeutic Implications
  • Consent
  • Advantages and risks of treatment
  • Likelihood of getting desired results
  • Are there any alternatives?

37
Prevalence of obesity by sex and ethnic group,
1999, England
Health Survey for England (2001)
www.heartstats.org
38
Percentage of adults perceiving severe lack of
social support by sex and ethnic group, 1999,
England
www.heartstats.org
Health Survey for England (2001)
39
Health Survey for England 2004 Health of ethnic
minorities
  • Study of 8,000 adults and 4,000 children in
    England from Bangladeshi, Black Caribbean, Black
    African, Irish, Pakistani, Indian, Chinese and
    groups
  • obesity does not seem to have a clear association
    with diabetes, CHD and stroke

40
Metabolic Syndrome
  • Analysis of 10,300 civil servants showed a clear
    link between the amount of stress experienced at
    work and symptoms of metabolic syndrome.
    Chandola, Brunner, Marmot. (2006). BMJ
  • The prevalence of the metabolic syndrome did not
    increase in Mexico City between 1990-1992 and
    1997-1999 despite more central obesity.
  • Diabetes Care. 2005 Oct28(10)2480-5

41
McDonaldizing Mens Bodies?
  • Dom thought his hypertension was related to
    the stresses of moving to his current place of
    residence where his young children were bullied
    on account of his weight, and where teenage boys
    smeared excrement on his car door handles.

  • Monaghan, 2006

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43
Ethics of Promoting Weight Loss
  • Promoting weight loss essentially suggests
    that thinness is the desired goal irrespective of
    health. Inherent in that message is the
    underlying assumption that fatness is undesirable
    which in turn perpetuates size discrimination.
  • Hawks SR, Gast JA. The ethics of promoting weight
    loss. Healthy Weight Journal 200014(3)25-26.

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47
Implications for Practice
  • Ensure evidence based practice
  • Promote health not thinness
  • Consistent and systematic

48
Tenets of Size Acceptance
  • Self-esteem and body image are strongly
    linked. Helping people feel good about their
    bodies can help motivate and maintain healthy
    behaviours.

49
Health For All
  • Good health is not defined by body size it is
    a state of physical, mental and social wellbeing

50
Assessment
  • Heavy with intuitive eating pattern
  • Overeating in response to food deprivation
  • Preoccupied with food due to past dieting
  • Weight gain after reduced activity levels
  • Emotionally troubled intuitive eater
  • Emotionally troubled with eating distress
  • Weight gain after starting medication
  • Melcher 1998

51
FAQ
  • Does trying to making fat people thin improve
    their health?
  • Wouldnt a no-diet approach to CR give people
    permission to eat what they like?
  • What if someone wants to lose weight for their
    own confidence?

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53
INDD 2007
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55
Atrium Health Ltd.
Lucy.aphramor_at_uhcw.nhs.uk 024 76965688
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